Healthcare Provider Details

I. General information

NPI: 1134904220
Provider Name (Legal Business Name): FYZICAL GURNEE CLINICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34498 N OLD WALNUT CIR STE A
GURNEE IL
60031-4202
US

IV. Provider business mailing address

34498 N OLD WALNUT CIR STE A
GURNEE IL
60031-4202
US

V. Phone/Fax

Practice location:
  • Phone: 224-252-2922
  • Fax:
Mailing address:
  • Phone: 224-252-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY J LANZILLOTTI
Title or Position: MANAGER
Credential: PT
Phone: 224-252-2922